Surgical treatment of persistent type 2 endoleaks, with increase of the aneurysm sac: indications and technical notes.

OBJECTIVE: Unsolved type 2 endoleaks and aneurysmal sac increasing after endovascular aneurysm repair (EVAR) can be fixed with surgical sacotomy, ligation of the patent backbleeding vessels and preservation of the endograft. The aim of the paper is to highlight the technique as a feasible procedure in alternative to the removal of the graft. MATERIALS AND METHODS: Four male patients whose aneurysm sac maximum transverse diameter had increased by 5 mm or more, without evidence of endoleak, migration or structural alteration of the endografts. The surgical access was by medial laparotomy in one case, flank incision in two cases and mini-laparotomy with laparoscopic assistance in the fourth case. Patients were followed with spiral CT and duplex ultrasound at discharge and at 6-12 months. RESULTS: All procedures were carried out, without complication. Two patients required intensive care unit (ICU) admission and the average post-operative hospital stay was 10 days (range 6-13). All patients are currently alive with a functioning endograft, at an average follow-up of 14.7 months. CONCLUSIONS: Sacotomy, leaving the endograft in place, appears to be a feasible therapeutic option, less invasive than conversion to open repair. This technique merits further study.

[Solid pseudopapillary tumour of the pancreas. Report of a case]. / Il tumore solido pseudopapillare del pancreas. Presentazione di un caso clinico.

Solid pseudopapillary pancreatic tumour is an uncommon disease including 2.7% of exocrine malignancies of the pancreas. Its low incidence is associated with an uncertain prognosis and with difficult diagnostic and therapeutic problems, despite routine use of ultrasonography, TC and RMN. A case of solid pseudopapillary pancreatic tumour in a young woman is reported: the clinicopathologic features, diagnostic imaging and surgical treatment are discussed. Surgery is the primary option. Prognosis is however not fully known. From a review of the literature it is suggested that these tumours should be regarded as potentially malignant.

Dissociation between carotid artery lesions and lipid parameters in recipients of successful kidney graft.

BACKGROUND: The relationships between lipid levels and atherosclerotic lesions of carotid arteries in kidney graft recipients are still unclear. METHODS: We evaluated carotid morphology in 53 recipients of functioning renal transplantation, and studied the relationship of carotid artery wall lesions with relevant clinical and laboratory risk factors for cardiovascular disease. The patients were on stable, cyclosporine-based immunosuppressive therapy. RESULTS: The main clinical characteristics of patients were: age, 46.5 +/- 10.1 years; males/females, 40/13; body mass index, 25.8 +/- 4.4 kg/m2; duration of transplantation, 43 +/- 52 months. Ultrasonographic scanning of carotid arteries showed the presence of lesions (intimal-media thickness and/or plaque) in 28 patients (52.8%). These recipients differed from patients without carotid lesions in terms of age (50.4 +/- 9.0 vs 42.2 +/- 9.7 years, p < 0.01) and duration of pre-transplant dialysis (4.6 +/- 3.4 vs 2.3 +/- 1.9 years, p < 0.01), whereas no statistically significant difference was observed as for total cholesterol (230 +/- 44 vs 235 +/- 35 mg/dl), LDL-cholesterol (142 +/- 32 vs 143 +/- 30 mg/dl), HDL-cholesterol (52 +/- 12 vs 58 +/- 20 mg/dl) and triglycerides (178 +/- 94 vs 167 +/- 89 mg/dl). The percentage of post-transplant diabetes was 3-fold higher in patients with carotid lesions (25 vs 8%). No difference was observed as for the following parameters: body mass index, duration of transplantation, fibrinogen levels, DDimer concentrations, reactive C-protein values, prevalence of hypertension, percentage of smokers vs non-smokers. CONCLUSIONS: The present study supports the view that carotid artery lesions in kidney graft recipients on stable, cyclosporine-based immunosuppressive therapy may not be related to circulating lipid values.

General anesthesia with spontaneous ventilation without intubation for short-stay operations.

BACKGROUND: The choice of the anesthetic technique plays a decisive role in the use of operating protocols in day hospital or short-stay given that full compliance with surgical needs must be associated with rapid recovery and the patient's renewed autonomy leading to discharge in total safety. METHODS: The use of spontaneous ventilation general anesthesia without intubation is proposed for all operations not requiring muscular paralysis and where the patient's conditions are compatible. The authors describe the technique used and its utilisation in over 4,000 patients undergoing orthopedic surgery of the leg. RESULTS: Using rapid clearance drugs with minimum metabolic involvement this anesthetic technique allows a full postoperative recovery within a short time and with no immediate or long-term sequelae. CONCLUSIONS: It can be used for short-stay or day-case surgery when concomitant with adequate surgical requirements.

Duplex ultrasonographic study of the renal arteries before and after renal artery stenting.

The aim of our study was to evaluate feasibility and accuracy of colour-coded duplex US in the detection of renal artery stenosis before and after stenting. Eighty-four patients (23 women, 61 men; mean age 64 years) with significant renal artery stenosis were studied with Doppler US, before and after stenting. A combined anterior and translumbar approach was used to visualise the renal arteries. Renal artery stenosis and in-stent restenosis were proved by the increase of renal peak systolic velocity (PSV) and reno-aortic ratio (RAR). Laboratory-specific threshold values of PSV and RAR were used to assess sensitivity and specificity of Doppler US. The renal arteries were visualised in all patients (feasibility 100%). A statistically significant difference of PSV and RAR was demonstrated between patent and stenotic renal arteries, before stenting, and between stenotic and stented renal arteries. No difference was demonstrated in cases of in-stent restenosis ( n=21). Before stenting, sensitivity of PSV and RAR was 93%, whereas specificity rates were 92 and 96%, respectively. After stenting sensitivity and specificity rates were, respectively, 90 and 93% for PSV, and 95 and 95% for RAR. Doppler US represents a feasible and reliable technique in the detection of renal artery stenosis and in-stent restenosis, although laboratory-specific threshold values are required to improve its accuracy.

[Surgical complications following pancreaticoduodenectomy: results of a single center experience]. / Le complicanze chirurgiche post-duodenocefalopancreasectomia: risultati di una esperienza monocentrica.

Pancreaticoduodenectomy represents the only therapeutic option for cefalo-pancreatic and periampullary cancers. Surgical and anaesthesiological techniques development over the last twenty years has granted an operative mortality decrease. However, surgical morbidity is still high, with an incidence of 30-50%. A 20 year experience of a single Centre is examined retrospectively: 121 patients underwent pancreatic resection with radical intent. Type of operation or re-operation, operative mortality within 30 days, general and surgical morbidity, postoperative hospital stay were analysed. Average recovery time was 24 days (range 12-65); operative mortality was 5.8% (7/121); general morbidity, including medical and surgical complications, was observed in 47 patients (38.8%). Pancreatic fistula occurred in 16 patients (13.2%); ten of these underwent a second operation. Patients who underwent pancreaticoduodenctomy were divided as follows: 76 pts. received a pylours-preserving pancreaticoduodenectomy and 45 a Whipple's resection. Neither surgical complications incidence nor mortality rate were significantly different between the two groups. Postoperative complications following pancreaticoduodenectomy are still frequent and severe. In particular, pancreatic fistula represents the most relevant complication following pancreaticoduodenectomy. The Authors suggest that standard and meticulous surgical procedures together with continued efforts to improve postoperative follow-up, support early detection of complications and improvement of results in most patients.

[Central segmental pancreatectomy in benign and borderline neoplasms of the pancreatic isthmus and body]. / La pancreasectomia segmentaria centrale nelle neoplasie benigne e borderline dell'istmo e del corpo del pancreas.

We report our experience with middle segment pancreatectomy for benign, cystic and borderline tumours of the neck and body of the pancreas. The guidelines for management of these tumours are unclear. Formerly they were usually resected with a pancreatico-duodenectomy or distal pancreatectomy including the spleen. However, such operations may cause high morbidity, a notable wastage of normal tissue and an unnecessary risk of diabetes mellitus and splenic loss. Four patients (age range: 34-72 years) with tumours of the neck or body of the pancreas underwent a middle segmental pancreatectomy. The cephalic stump was sutured with duct ligation. The distal stump was anastomosed with a Roux-en-Y jejunal loop. Neither pancreatic fistulas nor operative death occurred in any of the patients. In 3 patients with serous cystadenoma and in one with mucinous cystadenoma, the tumours measured 3.5 to 7 cm in size. These were located in the neck and body of the pancreas and could not be safely enucleated without compromising the pancreatic duct. All tumours were resected with clear margins. The mean operative time was 230 minutes and the median postoperative hospital stay 14 days (range: 10-23 days). The patients have been followed up for five years after surgery and all are disease-free. None of the patients became diabetic or presented exocrine insufficiency. Middle segment pancreatectomy may be an appropriate technique for selected benign or borderline pancreatic tumours in the neck and body of the pancreas. This procedure has an acceptable surgical risk when compared to that of major pancreatic resections and preserves pancreatic function and the spleen.

Renal artery stenting in patients with a solitary functioning kidney.

PURPOSE: To retrospectively evaluate the results of renal artery stenting in patients with renovascular disease and a solitary functioning kidney. METHODS: Palmaz stents were placed in 16 patients with a solitary functioning kidney, renal artery stenosis, hypertension and renal failure. Stenoses were evaluated with color Doppler ultrasound, MR angiography and digital subtraction angiography (DSA). Indications for stenting were: recoil after percutaneous transluminal renal angioplasty (PTRA) (63%), arterial dissection after PTRA (13%) and primary stenting (25%). Immediate results were evaluated by DSA. On follow-up (6-36 months), patients underwent periodical evaluation of clinical conditions (blood pressure and serum creatinine level) and stent patency, by means of color Doppler ultrasound. RESULTS: Stent placement was successful in all patients (100%). Cumulative primary patency rate was: 100% at 1 day, 93.75% at 6 months, 81.25% at 12 months and 75% at 24 months. A significant reduction in diastolic blood pressure occurred (mean +/- SD 104 +/- 6 vs 92 +/- 3; p < 0.05); renal function improved or stabilized in over 80% of patients. However, there was no significant difference in the creatinine values before and after treatment (mean +/- SD 200 +/- 142 micromol/l vs 197 +/- 182 micromol/l; p > 0.05). CONCLUSION: Renal artery stenting, both after PTRA and as primary stenting, represents a safe procedure, able to preserve renal function in patients with a solitary functioning kidney.

Low-dose dobutamine responsiveness in idiopathic dilated cardiomyopathy: relation to exercise capacity and clinical outcome.

AIMS: To evaluate myocardial contractile reserve using low-dose dobutamine echocardiography in patients with chronic heart failure secondary to idiopathic dilated cardiomyopathy stratified by peak exercise oxygen consumption (VO(2)). METHODS AND RESULTS: Sixty clinically stable patients (56+/-11 years; 45 males) with idiopathic cardiomyopathy and NYHA class I to III symptoms of heart failure were studied and followed-up for 13+/-3 months. All patients underwent cardiopulmonary exercise testing and low-dose dobutamine. The dobutamine infusion protocol consisted of an initial dose of 2.5 micro. kg(-1)per 3 min, increasing by 2.5 micro. kg(-1)per min every 3 min; the maximal dose was 10 micro. kg(-1)per min. The end-systolic volume index, left ventricular ejection fraction and cardiac output were measured at baseline and peak dobutamine dose and their change calculated as ((peak dose value-baseline value)/baseline value]x100. Ten normal subjects with normal left ventricular function and no coronary artery lesions served as a control group to compare low-dose dobutamine results. All analysed echocardiographic variables either at baseline or following dobutamine infusion were significantly lower in patients with chronic heart failure as a whole compared to the control group. When the patients were grouped according to Weber's classification, a statistically significant decrease in percentange changes in end-systolic volume index (rho=-0.77;P<0.0001), left ventricular ejection fraction (rho=-0.72;P<0.0001) and cardiac output (rho=-0. 82;P<0.0001) from class A to class C was observed. The mean percentage decrease in end-systolic volume index following the dobutamine infusion was 28.7+/-9% in class A (peak VO(2)>20 ml. kg(-1). min(-1)), 18.6+/-8% in class B (peak VO(2)between 16 and 20 ml. kg. min(-1)), and only 6.4+/-6% in class C (peak VO(2)between 10 and 16 ml. kg(-1). min(-1)) patient groups. At multivariate analysis, only the percentage change in end-systolic volume index was significantly associated with a peak VO(2)<15 ml. kg(-1). min(-1)(P=0.006). During the follow-up, 17 patients had events (15 readmissions for worsening heart failure and two deaths). At multivariate analysis, only the percentage change in end-systolic volume index was significantly associated with the occurrence of events (P=0.003). The area under the receiver operating characteristic curve for percentage change in end-systolic volume index was not significantly different from that for peak VO(2)(0. 86+/-0.04 vs 0.80+/-0.06;P:ns). CONCLUSION: This study indicates that in patients with chronic heart failure secondary to idiopathic cardiomyopathy, the cardiac response to low-dose dobutamine, as assessed by echocardiography, is correlated with peak VO(2), an objective and accurate measure of the severity of the disease and clinical outcome.

Noninvasive assessment of renal artery stenosis: current imaging protocols and future directions in ultrasonography.

Doppler ultrasound is one of many modalities that have been evaluated for the detection of renal artery stenosis. The lack of standardization in examination protocols and diagnostic criteria, as well as the wide differences in reported accuracy among different laboratories have, however, prevented universal acceptance of this technique as a reliable screening test for renal artery stenosis. The recent introduction of ultrasound contrast agents has substantially expanded the potential of color Doppler ultrasound. The use of microbubble echoenhancers in combination with harmonic Doppler imaging has been shown to improve diagnostic confidence by improving the operator's ability to visualize the renal arteries, and to significantly reduce the number of equivocal examinations. Moreover, contrast-enhanced Doppler ultrasound can provide functional information through analysis of renal time-intensity wash in/wash out curves. State-of-the-art contrast-enhanced Doppler ultrasound seems to have the potential to become a useful screening test for patients at risk from renovascular hypertension.

Effects of atrial pacing stress test on ultrasonic integrated backscatter cyclic variations in normal subjects and in patients with coronary artery disease.

AIMS: To evaluate the effects of acute, atrial pacing-induced, reversible myocardial ischaemia on myocardial thickening and integrated backscatter cyclic variations in patients with or without coronary artery disease. METHODS AND RESULTS: Thirty-six patients with suspected coronary artery disease underwent transoesophageal echocardiography with simultaneous atrial pacing, and coronary angiography. In myocardial segments not related to a significantly narrowed coronary artery, both from patients with and without coronary artery disease, thickening and integrated backscatter cyclic variations were not reduced at peak pacing. In segments related to a significantly narrowed coronary artery, thickening decreased at peak pacing, was still reduced at pacing interruption and recovered at 2 min, while backscatter cyclic variations, blunted at peak pacing, immediately recovered after pacing interruption. CONCLUSION: During stress-induced myocardial ischaemia, backscatter cyclic variations are blunted and thickening reduced. Returning to baseline, pre-atrial pacing values occur more rapidly in backscatter cyclic variations than when thickening takes place. Evaluation of stress-induced alterations in backscatter cyclic variations may aid in the identification of ischaemia-induced regional left ventricular functional impairment and, hence, in coronary artery disease diagnosis.

[Diagnosis of coronary disease using multiplane transesophageal echocardiography and atrial pacing]. / Diagnosi di malattia coronarica mediante ecocardiografia transesofagea multiplanare e pacing atriale.

The diagnostic value of echo-pacing has been previously report. Recently, monoplanar transesophageal echocardiography (TEE) has been used to improve the reliability of this stress procedure. Therefore, in 40 consecutive patients undergoing coronary angiography for suspected coronary artery disease (CAD) we tested the accuracy of atrial pacing (TAP) during multiplane TEE as a stress procedure. TAP was performed during TEE using a circular, adhesive electrode installed at the tip of the echoscope and connected to the pulse generator. In all patients TAP was firstly attempted by positioning the TEE probe in the esophagus and, if not successful, in the stomach. Left ventricular wall motion was monitored by means of 4, 2 chamber and long axis views from the esophagus and short axis scan from the stomach, in baseline conditions, at peak pacing and immediately after maximal heart rate. The test was considered positive if wall motion abnormalities developed during TAP. Stable capture of the atrium was obtained in 28 patients from the esophagus and in 6 patients from the stomach. Thus, TEE-TAP was performed in 34/40 patients (feasibility 85%). Wall motion abnormalities were detected during TAP in 20/24 with and in 2/10 patients without CAD. Thus, sensitivity and specificity of TEE-TAP were 83% and 80% respectively. The sensitivity of the test in single and multivessel disease resulted 72% and 92%. The 12 lead electrocardiogram during TAP showed a sensitivity of 66% and a specificity of 40% (p < 0.01 vs TEE-TAP). In conclusion, TEE-TAP is a new approach for CAD evaluation providing a complete and accurate imaging of left ventricular wall motion.

Urinary albumin excretion and atherosclerosis in essential hypertension.

1. Increased urinary albumin excretion is common in patients with essential hypertension and is at least to some extent correlated with prevailing blood pressure levels. However, the generalized vascular dysfunction present in advanced atherosclerotic disease may independently influence this parameter. 2. To evaluate this possibility, we assessed blood pressure, ultrasonographic carotid thickness, cardiac mass, minimum forearm vascular resistances, metabolic parameters and the angiotensin-converting enzyme genotype in patients with untreated essential hypertension and atherosclerotic peripheral vascular disease (n = 11). The results were compared with similar data obtained in matched groups of patients with uncomplicated hypertension and with normotensive control subjects (n = 11 per group). 3. Urinary albumin excretion was higher in hypertensive patients with atherosclerosis than in those without complications; carotid thickness was higher in atherosclerotic patients and a positive, statistically significant correlation existed between this parameter and urinary albumin excretion. In the same patient group, systolic blood pressure, fasting insulin and triacylglycerol levels were elevated and correlated with urinary albumin levels. However, differences in urinary albumin excretion persisted after taking into account the influence of those parameters by analysis of covariance. The distribution of angiotensin-converting enzyme genotype patterns and values of cardiac mass and minimum forearm vascular resistances did not differ significantly among the experimental groups. 4. The data suggest that vascular status may influence urinary albumin excretion in patients with essential hypertension, while confirming the importance of systolic blood pressure levels as a determinant of the raised urinary albumin excretion.

Peripheral ischemic occlusive arterial disease: comparison of color Doppler sonography and angiography.

We examined 334 legs in 167 consecutive patients with advanced peripheral ischemic disease using color Doppler sonography and angiography. Angiography revealed 714 lesions (369 nonsignificant stenoses, 297 significant stenoses, and 48 occlusions) in the 334 legs examined. Overall, color Doppler sonography revealed diagnostic agreement with angiography in 668 of 714 lesions (93.5%), including 343 of 369 (92.9%) nonsignificant stenoses, 279 of 297 (93.9%) significant stenoses, and 46 of 48 (95.8%) occlusions. Overestimation occurred in 26 of 369 (7%) nonsignificant stenoses and 3 of 297 (1%) significant stenoses. Underestimation was observed in 15 of 297 (5%) significant stenoses and in 2 of 48 (4.2%) occlusions. Peak systolic velocity ratio correlated better (P < 0.01) than peak systolic velocity with diameter reduction percentage as assessed at angiography. Color Doppler sonography is an accurate noninvasive method for evaluating patients with peripheral ischemic disease.

[The imaging diagnosis of Sjögren's syndrome: echography, sialography and scintigraphy compared in the study of the salivary glands]. / Diagnostica per immagini della sindrome di Sjögren: ecografia, scialografia e scintigrafia a confronto nello studio delle ghiandole salivari.

The aim of the present study was to evaluate the sensitivity and specificity of the ultrasonography, in comparison with other methods of investigation (scintigraphy, sialography, and biopsy), in scanning morphostructural changes in the parotid gland in patient with Sjögren's syndrome. During the period June-October 1994, 34 patients (5 males and 29 females, age ranged between 20 and 88 years) with "sicca syndrome" underwent to echography, scintigraphy, sialography and biopsy. The diagnosis was confirmed or excluded using the European Community Epidemiologic Committee criteria for Sjögren's syndrome. Twenty-two patients out of 34 were affected by Sjögren's syndrome, while the others resulted as control subjects. The ultrasonographic investigation has shown 76.19% of sensitivity and 30.43% of specificity. Even if echography is a non-invasive method, which could be used as preliminary approach for studying the diffused involvement of the parotid gland, at the status of the art, it is not completely reliable for the global evaluation of the morphostructural changes in patients with Sjögren's syndrome, in comparison with the other techniques. Because of the double nature of the gland injury, it appears to be essential the diagnostic integration between echography and sialography.

Relationship between carotid wall thickness and forearm blood flow reserve in hypertension.

BACKGROUND: The development of a reduced forearm blood flow reserve and an increased carotid intima media thickness is a well known consequence of the structural adaptation of arterioles and large arteries in response to hypertension. It is unknown, however, how those two processes relate to each other in the individual hypertensive patient. METHODS: Minimal forearm vascular resistances (Rmin, the ratio of mean blood pressure to postischemic plethysmographic peak forearm blood flow), common carotid intima media thickness (IMT, high-resolution ultrasonography), blood pressure (indirect method), left ventricular mass, posterior wall and septum thickness (by echocardiography) and lipids were measured in 15 men with mild-to-moderate essential hypertension without evidence of atherosclerotic involvement of the carotid arteries, and in 14 normotensive controls with a similar age range. RESULTS: Rmin and IMT were greater in hypertensives, and a statistically significant positive correlation existed between the two variables. Both Rmin and IMT correlated with left ventricular structure indices and blood pressure. Age showed a positive correlation with IMT, while lipids were unrelated to either parameter. CONCLUSIONS: The micro- and macrovascular segments of the hypertensive circulation readapt in parallel in response to elevated blood pressure, possibly through the commensurate development of medial hypertrophy.

Human immunodeficiency virus-associated Hodgkin's disease contains latent, not replicative, Epstein-Barr virus.

Severe immunodeficiency is associated with reactivation of latent Epstein-Barr virus (EBV) that is manifested by virus replication. It is unknown whether EBV replication also occurs in the Hodgkin's disease (HD) tissue of patients infected with the human immunodeficiency virus (HIV). Therefore, we studied paraffin-embedded lymph nodes from 13 cases of HIV-associated HD to determine the latent or replicative state of EBV infection. All patients were seropositive HIV-infected men; additional clinical information was available for 12 patients. The risk factor(s) for HIV infection were homosexuality (n = 7), intravenous drug abuse (n = 2), homosexuality and intravenous drug abuse (n = 1), sexual promiscuity (n = 1), or hemophilia (n = 1). Advanced clinical stage and B symptoms were common at the time of initial diagnosis of HD. The histological subtype of Hodgkin's disease was universally mixed cellularity, except for a single case classified as nodular sclerosis. Seven cases exhibited foci of relative lymphoid depletion. Five cases contained foci of necrosis. Reed-Sternberg (RS) cells and RS cell variants were positive for CD30/BerH2 and negative for CD45/LCA, CD45RO/UCHL1, and CD20/L26 in all cases. Tumor cells were positive for CD15/LeuM1 in seven cases. In all 13 cases, RS cells and RS cell variants were infected by latent EBV as shown by in situ hybridization to EBV-encoded ribonucleic acid (EBER1). In 12 of 13 cases neoplastic cells coexpressed EBV latent membrane protein 1 (LMP1). EBV replication was examined by two different methods: immunohistochemistry to identify EBV-encoded BZLF1 protein and in situ hybridization to detect EBV BHLF1 transcripts. No positivity in RS or RS cell variants was detected with either assay of EBV replication (95% confidence interval [CI] = 0% to 23%). The findings confirm that EBV is detected more frequently in HIV-associated HD when compared with immunocompetent patients with HD. The findings also suggest that EBV is tightly latent within RS and RS cell variants of HIV-associated HD. It appears that factors other than host immune status are important in maintaining EBV latency in HIV-associated HD.

[Assessment of viable myocardium after infarction with transesophageal echocardiography and myocardial echocontrastography]. / Valutazione del miocardio vitale nel postinfarto mediante ecocardiografia transesofagea ed ecocontrastografia miocardica.

Left ventricular recovery of dysfunctioning but viable myocardium can occur only in tissue in which both myocardial contractile reserve and microvascular integrity are preserved. Recent studies have demonstrated that both inotropic stimulating echo tests and myocardial contrast echocardiography can be used to assess myocardial viability in post-myocardial infarction patients. Therefore we performed a transesophageal and myocardial contrast echocardiographic evaluation of post-myocardial infarction patients to assess: the respective accuracy of post-extrasystolic potentiation and low-dose dobutamine (5 and 10 mcg) during transesophageal echocardiography in eliciting contractile reserve, and the potential of myocardial contrast echocardiography in predicting later functional recovery. Results of our studies showed comparable effects of low-dose dobutamine (5 mcg) and post-extrasystolic potentiation in increasing myocardial thickening while low-dose dobutamine (10 mcg) had a greater potential in eliciting residual contractility. Lastly, myocardial contrast echocardiography provided a clear spectrum of intramyocardial perfusion patterns in dysfunctioning areas but did not accurately correlate with later functional recovery as better predicted by low-dose dobutamine in the same segments. In conclusion, these methods represent the preferred choice of studying the perfusion-contraction match in viable myocardium thus playing an important role in prognostic and therapeutic strategies in myocardial infarction patients.

Coronary flow dynamics and reserve assessed by transesophageal echocardiography in obstructive hypertrophic cardiomyopathy.

Myocardial ischemia is frequently associated with left ventricular outflow obstruction. To assess coronary flow impairment in obstructive hypertrophic cardiomyopathy (HC), 10 patients with echo-Doppler-detected obstructive HC and normal coronary arteries underwent transesophageal echo-Doppler examination of both coronary flow velocity (CFV) at rest, recorded in the proximal left anterior descending coronary artery, and coronary flow reserve (CFR) evaluated by means of dipyridamole infusion response. Ten normal patients were similarly studied and served as a control group. Two relevant alterations in coronary flow dynamics were detected in patients with HC: (1) a significantly increased diastolic/systolic CFV ratio, and (2) a significantly reduced dipyridamole/baseline CFV ratio. Compared with normal subjects, the CFV pattern showed a significantly greater diastolic and a significantly lower systolic component at rest (in some patients it was reversed). Diastolic/systolic CFV ratio was significantly higher in patients with HC at baseline (3.1 +/- 1 vs 1.6 +/- 0.5; p < 0.01) and increased further after dipyridamole infusion (4.9 +/- 2 vs 2.2 +/- 0.7; p < 0.01). In addition, CFR was impaired in patients with HC (1.8 +/- 0.3 vs 3.1 +/- 0.5; p < 0.01). Furthermore, a significant correlation between CFR and intraventricular pressure gradient was found. Thus, transesophageal echo-Doppler examination is a useful tool for evaluating CFV dynamics and CFR as demonstrated in patients with obstructive HC.